Proactive Psychiatry Intervention Using a Nurse-Led Behavioral Response Model for Hospitalized Patients With Behavioral Disturbances Background: The health care sector has one of the highest rates of workplace violence, putting staff at risk and impeding care. To deliver quality health care, staff need targeted resources. This article describes a program to improve staff safety and reduce barriers to care for patients with behavioral disturbances. Program Description: A nurse-led behavioral response team was created to identify high-risk patients and offer prompt targeted interventions. The Behavioral Optimization and Outcomes Support Team (BOOST) was implemented in November 2012, in conjunction with a proactive model of care, enabling psychiatric intervention. Advanced practice nurses in psychiatry respond to requests from staff on medical/surgical units to assist with management of behavioral disturbances. Methods: Consultation and intervention data were reviewed, and staff satisfaction surveys were completed to evaluate the program. Results: The program has contributed to staff feeling more supported and safer at work. There has also been a reduction in staff's experience of perceived burden in the care of patients with behavioral disturbances although they are caring for more of these patients. Conclusions: Although violence risk in health care continues to be a significant issue, programs to intervene early can be effective in supporting staff to minimize these risks.

Automation of the I-PASS Tool to Improve Transitions of Care Introduction: Errors in communication during handoffs are a significant source of medical error and put patients at risk. The I-PASS system was designed to systematically communicate information to the oncoming healthcare provider and has been shown to decrease the risk of communication errors. The objective of this observational quality improvement study was to determine whether the addition of a partially automated, electronic handoff tool would further decrease errors in communication during transitions of care for inpatient medical teams. Methods: We created an electronic tool to incorporate user-generated patient information in the I-PASS format with automatically compiled data derived from the electronic medical record. Numbers of errors in the printed handoff document were recorded before and after intervention. Results: The first implementation cycle demonstrated an absolute risk reduction for written errors of 45.6% (95% confidence interval [CI] 39.2–51.2%) and a number needed to treat (NNT) of three patients. The second cycle showed an absolute risk reduction of 53.3% (95% CI 39.8–63.9%; NNT 2). Aggregate data showed an absolute risk reduction of 46.6% (95% CI 41.0–51.7%, NNT 3). Conclusions: Improving the routine task of patient handoff through the thoughtful application of technology can yield benefits in terms of decreasing documentation errors and streamlining workflow before patient handoff.

Shared Care During Breast and Colorectal Cancer Treatment: Is It Associated With Patient-Reported Care Quality? There is growing evidence that shared care, where the oncologist, primary care physician, and/or other specialty physicians jointly participate in care, can improve the quality of patients' cancer care. This cross-sectional study of breast and colorectal cancer patients (N = 534) recruited from the New Jersey State Cancer Registry examined patient and health system factors associated with receipt of shared care during cancer treatment into the early survivorship phase. We also assessed whether shared care was associated with quality indicators of cancer care: receipt of comprehensive care, follow-up care instructions, and written treatment summaries. Less than two-thirds of participants reported shared care during their cancer treatment. The odds of reporting shared care were 2.5 (95% CI: 1.46–4.17) times higher for colorectal than breast cancer patients and 52% (95% CI: 0.24–0.95) lower for uninsured compared with privately insured, after adjusting for other sociodemographic, clinical/tumor, and health system factors. No significant relationships were observed between shared care and quality indicators of cancer care. Given a substantial proportion of patients did not receive shared care, there may be missed opportunities for integrating primary care and nononcology specialists in cancer care, who can play critical roles in care coordination and managing comorbidities during cancer treatment.

Regional Adoption of Primary Care—Mental Health Integration in Veterans Health Administration Patient-Centered Medical Homes Introduction: Behavioral health integration is important, yet difficult to implement, in patient-centered medical homes. The Veterans Health Administration (VA) mandated evidence-based collaborative care models through Primary Care–Mental Health Integration (PC-MHI) in large PC clinics. This study characterized PC-MHI programs among all PC clinics, including small sites exempt from program implementation, in one VA region. Methods: Researchers administered a cross-sectional key informant organizational survey on PC-MHI among VA PC clinics in Southern California, Arizona, and New Mexico (n = 69 distinct sites) from February to May 2018. Researchers analyzed PC clinic leaders' responses to five items about organizational structure and practice management. Results: Researchers received surveys from 65 clinics (94% response rate). Although only 38% were required to implement on-site PC-MHI programs, 95% of participating clinics reported providing access to such services. The majority reported having integrated, colocated, or tele-MH providers (94%) and care management (77%). Most stated same-day services (59%) and “warm” handoffs (56%) were always available, the former varying significantly based on clinic size and distance from affiliated VA hospitals. Conclusions: Regional adoption of PC-MHI was high, including telemedicine, among VA patient-centered medical homes, regardless of whether implementation was required. Small, remote PC clinics that voluntarily provide PC-MHI services may need more support.

Factors Associated With Hospitalization Before the Start of Long-Term Care Among Elderly Disabled People The growing number of elderly people with functional limitations, cognitive impairment, and disability is an organizational challenge for the health care sector. This study investigated the factors associated with hospitalization in the period between evaluation and the start of a long-term care (LTC) program for patients on the waiting list. A population-based historical cohort study was performed using data extracted from different administrative databases. The cohort included disabled individuals 65 years and older who were evaluated for entrance into an LTC program between January 1, 2012, and December 31, 2013, in Tuscany, Italy. The sample consisted of 11,429 subjects. The characteristics positively associated with hospital admission were residence zone {urban incidence rate ratio (IRR) = 0.83 (95% confidence interval [CI] 0.74–0.94)}, number of prescribed drugs IRR = 1.01 (95% CI 1.00–1.02), a Charlson Comorbidity Index of 2 IRR = 1.44 (95% CI 1.26–1.64), and lower social conditions IRR = 0.99 (95% CI 0.98–1.00). The rate of hospitalization for patients with heart failure, chronic obstructive pulmonary disease, and dementia was higher than for patients without these diseases. Our results indicate that it may be possible to predict factors that can lead to hospitalization before the start of an LTC program.

Contextual Factors Associated With Quality Improvement Success in a Multisite Ambulatory Setting The Model for Understanding Success in Quality (MUSIQ) is a framework of contextual factors for quality improvement (QI) projects. We sought to determine which MUSIQ contextual factors were associated with successful QI initiatives. In a cross-sectional survey study, at a 21-site, ambulatory, urban primary care network, a modified MUSIQ survey tool questionnaire was administered to QI team members. The primary analysis associated objective measures of QI success with MUSIQ contextual factors. Objective QI success was defined as reaching goal percentages of adult patients with diabetes achieving glycated hemoglobin less than 8% and/or pediatric patients who had received combination toddler vaccines. Objective outcomes were compared with a subjective, self-reported outcome measure of QI success because previous literature found subjective outcomes were associated with specific MUSIQ factors. In the 143 survey responses collected, across 21 sites, no contextual factors from the MUSIQ survey were associated with either the adult or pediatric objective measure of QI project success. In a post hoc analysis, objective and subjective measures of success were often not associated and/or negatively correlated. In conclusion, contextual factors were not associated with objective measures of QI outcomes, in contrast to previous studies finding associations with subjective QI outcome measures.

Shared Medical Appointments in Preoperative Joint Replacement: Assessing Patient and Healthcare Member Satisfaction Background: Shared medical appointments (SMAs) have proven to be effective in improving patient access and education while augmenting productivity. In shifting from a traditional visit model, patient and interdisciplinary healthcare team (IHCT) member satisfaction is imperative. Predominantly seen in primary care, SMA use in orthopedics is limited. After identification of access and productivity concerns, the SMA was implemented as a quality improvement project in a rural clinic. The lower extremity joint replacement (LEJR) population was chosen because of multiple preoperative appointments and costs on the healthcare system. Purpose: To assess patients' and IHCT members' satisfaction levels in using an SMA for the preparation of LEJR. Relevance to Healthcare Quality: The SMA is an effective model offering an efficient, cost-effective methodology aligning with the Institute for Healthcare Improvement's Triple Aim. Results: Twenty SMAs were conducted. Sixty-three patients and 14 ICHT members participated. Mean (M) satisfaction rating for SMA patients (M = 4.90, SD 0.26) was significantly higher than mean for traditional patients (M = 4.03, SD 0.39). Interdisciplinary healthcare team members' attitudes toward SMAs revealed a mean score of 4.58. Incidentally, cycle times improved as did lengths of stay. Conclusions: Lower extremity joint replacement patients and IHCT members reported high satisfaction with SMAs.

Narcotic Pain Control for Ureterolithiasis Is Associated With Unnecessary Repeat Imaging in the Emergency Department A subset of patients with ureteral stones who present to the emergency department (ED) will return with recurring symptoms and will receive unnecessary repeat imaging. We retrospectively identified 112 patients from 2012 to 2016 diagnosed with at least one ureteral stone on computerized tomography (CT) at our institution who returned to the ED within 30 days. Patients were stratified based on the presence or absence of repeat CT scan imaging. Mean values were compared with independent t-test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of repeat imaging. Sixty-eight patients (60.7%) underwent repeat CT scan imaging upon representation to the ED within 30 days of being diagnosed with ureterolithiasis. Ureteral stone position changed in 34 patients (30.4%) who underwent repeat imaging. On univariate analysis, younger age, nondiabetics, narcotics prescribed on discharge from first ED visit, and longer mean time between ED visits were associated with repeat CT scan imaging being performed (p < .05). Only prescription of narcotic pain medications was an independent predictor of repeat CT scan imaging (odds ratio: 3.18, 95% confidence interval: 1.22–8.28; p = .018). Nonsteroidal anti-inflammatory drugs or nonnarcotic pain medications, therefore, should primarily be used for pain control in these patients to avoid unnecessary testing.

A Student-Led, Multifaceted Intervention to Decrease Unnecessary Folate Ordering in the Inpatient Setting To reduce unnecessary laboratory testing, a three-phase intervention was designed by students to decrease serum folate laboratory testing in the inpatient setting. These included an educational phase, a personalized feedback phase, and the uncoupling of orders in the electronic medical record. Average monthly serum folate ordering decreased by 87% over the course of the intervention, from 98.4 orders per month at baseline to 12.7 per month in the last phase of the intervention. In the segmented regression analysis, joint ordering of folate and vitamin B12 significantly decreased during the intervention ([INCREMENT]slope = −4.22 tests/month, p = .0089), whereas single ordering of vitamin B12 significantly increased ([INCREMENT]slope = +5.6 tests/month; p < .001). Our intervention was successful in modifying ordering patterns to decrease testing for a deficiency that is rare in the U.S. population.